Inspection on 08/11/05 for Marray House

This inspection was carried out on 8th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Marray House 16/08/10

Marray House 03/08/10

Marray House 02/07/10

Marray House 15/04/10

Marray House 07/12/09

Marray House 28/07/09

Marray House 23/08/07

Marray House 20/11/06

Marray House 16/06/05

Marray House 24/11/04

Marray House 06/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Marray House 12-14 Essa Road Saltash Cornwall PL12 4ED Lead Inspector Mike Stokes Unannounced Inspection 8th November 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Marray House DS0000009195.V259968.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Marray House DS0000009195.V259968.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Marray House Address 12-14 Essa Road Saltash Cornwall PL12 4ED Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01752 844488 Mrs Enid Robertson Crofts Mr Peter William Crofts Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Marray House DS0000009195.V259968.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th June 2005 Brief Description of the Service: Marray House is registered to provide personal care and accommodation for up to 23 older persons. It is a detached house situated near the centre of Saltash, close to the shops, public transport and community facilities. Service users bedroom accommodation is provided on the ground and first floors. Stair lifts are provided to assist service users. Communal lounge, dining room, kitchen and laundry areas are provided on the ground floor. Mrs Crofts has been registered as a care provider for 27 years. Marray House DS0000009195.V259968.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection to review the standards of care provided at the home when the registered persons were unaware it was planned. I arrived at 11:00am and left at 3.00 pm. During this time I met service users, care staff and the senior carers managing the home. The senior carers assisted me in looking at records kept to monitor the welfare of service users and discussed developments at the home. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Marray House DS0000009195.V259968.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Marray House DS0000009195.V259968.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. The registered person has provided a statement of purpose and service users guide that details the facilities and services available within the home. The registered provider will assess all prospective service users prior to admission to ensure that the home can meet their care needs. EVIDENCE: A statement of purpose is available within the home and a service users guide has been issued to each service user. These documents explain the services and facilities available within the home as part of the contract and that hairdressing, chiropody and newspapers can be provided at the home and are at the service users expense. The registered provider or a senior carer will visit the prospective service users at their own home or in hospital prior to admission to complete an assessment process. These records include information received from other agencies to assist in appropriate admissions to the home. Marray House DS0000009195.V259968.R01.S.doc Version 5.0 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. The health needs of service users are met with evidence of multi disciplinary work occurring to provide for service users welfare. EVIDENCE: The existing care plans and weekly summary sheets for service users were reviewed with the senior carers on duty. The draft system to expand on the needs of service users regarding their health, social and personal care was discussed. The introduction of this method should provide details of the action staff must take to meet these needs and demonstrate a monthly review of these plans with the involvement of service users. A range of pressure relieving equipment is provided and appropriate liaison occurs with the community nursing service to provide for the welfare of service users. The senior carers maintain accurate records and appropriate procedures for the administration of medication to service users. The Pharmacist has reviewed the system and the report dated 18/10/05 was available for inspection. The Service users are registered with local GP’s in Port View Surgery and Saltash Health Centre. Service users spoken to expressed approval of the care received at the home and that they can access all support services as required. Marray House DS0000009195.V259968.R01.S.doc Version 5.0 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Service users exercise their choice to enjoy the privacy of their own rooms or join other service users in communal areas for company or meals. Service users maintain contact with visiting relatives and friends at the home. Service users are predominantly dependent on these contacts to access community facilities and the registered provider will organise visiting entertainers and group activities at the home. The meals provided in the home are good with special diets catered for. EVIDENCE: Service users were met in communal areas or their own rooms. Service users bring items of furniture and possessions such as televisions, radios and CD players. Service users expressed approval that regular visits are received from their relatives. The opportunity to meet visiting relatives did not occur but records of visits are maintained. A discussion occurred with service users and the cook on duty to discuss the catering arrangements and the main midday meal was observed. The main meal is at lunchtime and a choice is provided for the evening meal, with snacks and beverages also provided during the day. The menu was inspected and a range of nutritious meals is provided, including special diets. Service users expressed their approval of the traditional catering arrangements at the home. Marray House DS0000009195.V259968.R01.S.doc Version 5.0 Page 10 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The registered provider uses the policy and procedures at the home to assist in the protection of service users. EVIDENCE: The complaints procedure containing the Commissions contact number and address was displayed in the home and is detailed in the service users guide. The registered provider maintains a record of complaints received and how these have been dealt with appropriately at the home. The senior carer stated that day-to-day control and regular contact with service users provided the opportunity to monitor standards. The registered person has provided appropriate ‘Protection’ policy and procedures. A recommendation that staff attend the ‘Protection of Vulnerable Adults’ training provided by social services has been achieved. There is a policy regarding staff accepting gifts from service users and precluding staff involvement in the making or benefiting from service users wills. The homes insurance provides for service users to make claims on personal items and for public liability. The home provides appropriate records regarding finances and items held on behalf of service users. Marray House DS0000009195.V259968.R01.S.doc Version 5.0 Page 11 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. The registered provider is providing a reasonable standard of décor and maintenance to ensure service users live in a safe and comfortable environment. EVIDENCE: I met service users in the communal lounge areas and in their bedrooms. Service users can choose to use the communal areas of the home or enjoy the privacy of their bedroom accommodation at any time. There are sufficient and suitable bathroom, shower and toilet facilities. The home provides a call bell system, 4 stair lifts, bath hoist, mobile hoist, grab rails and various pressure relieving equipment is available within the home. Radiator covers have been provided in 9 rooms and this work should be completed for the remaining areas. Appropriate lighting and ventilation is provided, the windows have restrictive opening devices. The baths at the home have mixing valves to control the supply of hot water and the registered provider is currently providing safety valves to sinks to prevent the risk of scalding to service users. The home presented as clean, pleasant and hygienic. Marray House DS0000009195.V259968.R01.S.doc Version 5.0 Page 12 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. A stable staff team is receiving appropriate support and training opportunities to provide service users with a consistent approach to care. EVIDENCE: On the day of this unannounced inspection there were appropriate numbers of senior staff, carers and ancillary staff to present an organised home, providing for the welfare of service users. There is a minimum of 2 carers at all times with 3 carers at peak times of activity. A waker and sleeping night carer are provided for service users that require attention at night. Induction and foundation training are developed concerning ‘principles of care’ and staff training records show that NVQ level 2, Medication, First Aid, Basic Food and Hygiene, Fire Precautions and Manual Handling are provided. The 2 senior carers who are NVQ Assessors continue to develop and oversee these responsibilities and have developed the individual staff files to record training completed. Staff were observed to exhibit appropriate skills and attitudes during their interactions with service users. Marray House DS0000009195.V259968.R01.S.doc Version 5.0 Page 13 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35, 36, 37 and 38. The registered person is providing clear and effective leadership and management to maintain a safe and comfortable home for service users. EVIDENCE: The registered person has provided services at the home for 27 years and the 2 senior carers and other staff have also worked there for many years. The schedules 3 and 4 listing all records to be kept were reviewed and appropriate records are maintained at the home. The registered provider is completing risk assessments and the appropriate maintenance of health and safety precautions, training and equipment is occurring. Records regarding the maintenance of chair lifts, hoists, gas and electrical equipment are available. The Fire Safety Officer also visited the home 02/08/05 to review the fire precautions. Staff induction, supervision and training are provided. Marray House DS0000009195.V259968.R01.S.doc Version 5.0 Page 14 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 3 3 3 Marray House DS0000009195.V259968.R01.S.doc Version 5.0 Page 15 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The registered person should develop the care plans to expand on the needs of service users regarding health, social and personal care. The management should provide details of the action staff should take to meet these needs and demonstrate a monthly review of these plans with the involvement of service users. The registered person should complete a programme of providing radiator covers and safety valves on hot water outlets for the remaining areas in the home. 2. OP25 Marray House DS0000009195.V259968.R01.S.doc Version 5.0 Page 16 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Marray House DS0000009195.V259968.R01.S.doc Version 5.0 Page 17 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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